Unequal Access: Immigrants And US Health Care

Despite the important role that immigrants play in the
U.S. economy, they disproportionately lack health
insurance and receive fewer health services than native-born
Americans. Some policymakers have called for limits on immigrants'
access to health insurance, particularly Medicaid,
which are even more stringent than those already in place.
However, policies that restrict immigrants' access to some
health care services lead to the inefficient and costly use of
other services (such as emergency room care) and negatively
impact public health. The future economic success of the
United States depends on a healthy workforce. Therefore,
policies must be devised that improve, rather than restrict,
immigrants' access to quality health care.

Among the findings of this report:

In 1998, per capita health care expenditures were 55 percent lower for immigrants than for natives. Although immigrants comprised 10 percent of the U.S. population, they accounted for only 8 percent of U.S. health care costs.

In 1998, immigrants received about $1,139 per capita in health care, compared to $2,546 for native-born residents.

Despite the fact that all immigrants are eligible for emergency medical services, they had lower expenditures for emergency room visits, as well as doctor's office visits, outpatient hospital visits, inpatient hospital visits, and prescription drugs.

Immigrant children had 74 percent lower per capita health care expenditures than U.S.-born children in 1998. However, emergency room expenditures were more than three times higher among immigrant children than U.S.-born children despite the fact that immigrant children visited the emergency room less often. This suggests that immigrant children may be sicker when they arrive in the emergency room.

The primary reason that immigrants are using the health care system less than the native-born is lack of health insurance. According to 2002 data from the Survey of Income and Program Participation (SIPP), foreign-born adults are nearly three times as likely as native-born adults to be uninsured (32 percent vs. 13.4 percent, respectively).

Introduction

Despite the important role that immigrants play in the
U.S. economy, they disproportionately lack health
insurance and receive fewer health services than native-born
Americans. Nevertheless, some policymakers have called for
limits on immigrants' access to health insurance, particularly
Medicaid, which are even more stringent than those already
in place. In the absence of a federal solution to the failures
of U.S. immigration policy, politicians in states such as New
York, California, Texas, Arizona, and Florida have called for
removing the access and eligibility of illegal immigrants for
publicly supported health, social, and educational services.

However, concerns that immigrants are placing an undue
burden on the U.S. health care system as a whole are largely
unsubstantiated. Moreover, policies that restrict immigrants'
access to some health care services lead to the inefficient and
costly use of other services (such as emergency room care)
and negatively impact public health. Little attention has been
directed toward the development of policies and practices that
improve the well-being of immigrants, particularly immigrant
children. Policymakers have a responsibility to examine the
societal impact of health care restrictions on a group that
comprises 15 percent of the U.S. labor force. [1]

Immigrants Contribute To The Economy

Many studies have documented that immigrants contribute
significantly to the U.S. economy. For example,
the National Research Council estimated in 1997 that the
average immigrant pays about $1,800 more in taxes than he
or she uses in government services. The net tax contribution
of an immigrant and his or her children and grandchildren is
$80,000. [2] A 2005 report from the National Foundation for
American Policy concluded that new legal immigrants to the
United States will provide a net benefit of approximately $407
billion in present value to the Social Security system over the
next 50 years. The report also affirmed that any significant
reduction in legal immigration would worsen the financial
status of the Social Security system and make any reforms
to the system far more difficult to achieve. [3] In addition, the
Social Security system reaps an enormous benefit from the
taxes paid by undocumented immigrants. The Social Security
Administration (SSA) concluded in 2001 that undocumented
immigrants "account for a major portion" of the billions of
dollars paid into the Social Security system under names or
social security numbers that don't match SSA records and
which payees can never draw upon. [4] As of July 2003, these
payments totaled $421 billion. [5]

A Common Misconception

Although immigrants are net contributors to the U.S.
economy, the misconception remains that they are
a burden to native-born taxpayers. This view has spurred
legislative initiatives such as the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996 (PRWORA),
which created a five-year ban on Medicaid eligibility for new
legal immigrants and required that the income and resources
of a prospective immigrant's sponsor be used in calculating
eligibility to immigrate. PRWORA also prevented states from
using federal funds to provide Medicaid and State Children's
Health Insurance Program (SCHIP) coverage for most legal
immigrants who have resided in the United States for less
than 5 years. Prior to 1996, all legal permanent residents
had the same access to public benefits, including Medicaid,
as did U.S. citizens. [6]

However, research conducted before the passage of
PRWORA generally found that immigrants were less likely
than native-born Americans to use public services. [7] Data suggested
that the United States was not a "welfare magnet" for
undocumented migrants from Mexico. [8] A 1996 study by the
Carnegie Endowment for International Peace and the Urban
Institute concluded that "there is no reputable evidence that
prospective immigrants are drawn to the U.S. because of its
public assistance programs." [9]

Immigrants Consume Less In Health Care Than Natives

Immigrants account for a relatively small share of total U.S.
health care costs. According to a 2005 study, per capita health
care expenditures were 55 percent lower for immigrants than
for natives in 1998, even after adjusting for sociodemographic
characteristics. On average, immigrants received about $1,139
in health care, compared with $2,546 for native-born residents.
Although immigrants comprised 10 percent of the U.S.
population in 1998, they accounted for only 8 percent of U.S.
health care costs. Immigrant health care expenditures totaled
$39.5 billion in 1998, with about $25 billion reimbursed
by private insurers, $11.7 billion reimbursed by government
programs, and $2.8 billion paid out of pocket. Despite the fact
that all immigrants are eligible for emergency medical services,
they had lower expenditures for emergency room visits, as well
as doctor's office visits, outpatient hospital visits, inpatient
hospital visits, and prescription drugs {Figure 1}. [10]

A 2005 report by the University of California and the
Mexican government found that recent immigrants from
Mexico are half as likely to use emergency rooms as native-born whites and Mexican Americans. Fewer than 10 percent
of recent Mexican immigrants (both legal and undocumented)
who had been in the United States for fewer than ten years
reported using an emergency room in 2000, compared to 20
percent of native-born whites and Mexican Americans. Recent
immigrants also were more likely not to have seen a doctor in
the previous two years. Despite the fact that immigrants are
often in the most risky occupations (e.g. construction), they
are not using emergency rooms as often as the native-born. [11]
This raises an important question for policymakers: how will
immigrants work in their jobs, many of which are physically
demanding, without good health?

Disparities in health care expenditures are especially pronounced
among children. Immigrant children had 74 percent
lower per capita health care expenditures than U.S.-born
children in 1998. However, emergency room expenditures
were more than three times higher among immigrant children
than U.S.-born children {Figure 3} despite the fact that immigrant
children visited the emergency room less often. This
suggests that immigrant children may be sicker when they arrive
in the emergency room and probably reflects poor access
to primary care. [13] A 2001 study also found that non-citizen
children were less likely than citizen children to have made
both office-based visits and emergency room visits. [14]

Lack Of Health Insurance

The primary reason that immigrants are using the health
care system less than the native-born is lack of health
insurance. [15] According to 2002 data from the Survey of
Income and Program Participation (SIPP), foreign-born
adults are nearly three times as likely as native-born adults
to be uninsured (32 percent vs. 13.4 percent, respectively). [16]
Some studies have indicated that even immigrants with higher
rates of education and employment are more likely to be
without health insurance than their U.S.-born counterparts. [17]
Ultimately, these immigrants do not receive quality health
care and lack timely preventive services. Instead, they often
use health care mostly when they become sick. Due to poorer
access to health insurance, many immigrants avoid or delay
medical care because of financial burdens. [18]

A 2005 study found that the difference in insurance
coverage rates between U.S. natives and immigrants is explained
by the types of jobs that immigrants hold, as well
as personal characteristics that directly and indirectly affect
coverage. [19] A significant proportion of immigrants works in
low-paying jobs or jobs with small firms that do not offer
health insurance. Non-citizen immigrants in particular are
typically younger, less educated, and work in less-skilled jobs,
which is also the case with U.S. citizens who lack insurance.
Catherine McLaughlin, director of the Economic Research
Initiative on the Uninsured at the University of Michigan,
points out that "non-citizen immigrants are the 'canary in
the mine' for health insurance woes in the U.S. Their lack of
access to employment-based coverage is more pronounced
than other groups, but signals the vulnerability many face
as employment-based coverage becomes more difficult and
costly to secure." [20] Policies that improve employment-based
access to health insurance are imperative to improving the
health and well-being of the U.S. population.

Even among immigrants who are eligible for publicly
funded health insurance, such as Medicaid, fear and confusion
often create barriers to enrollment and to concern
about becoming a "public charge," which would make them
ineligible for U.S. citizenship in the future and could result
in deportation. [21] These fears persist despite outreach work
by community groups at the local level and Department of
Justice clarifications reaffirming that Medicaid and SCHIP
coverage must not be used in making public charge determinations.
A useful model for creating a one-stop shop where
immigrants can apply for public insurance without fear is
California's Children's Health Initiatives, which has been
especially successful in offering a seamless system of coverage
for undocumented children and their families. [22]

Consequences Of Poor Health Care

Lower rates of insurance coverage among immigrants
contribute to lower health care utilization, including
lower rates of cancer screening and other types of preventive
services. [23] Uninsured children are five times more likely to use
the emergency room as their usual source of care than privately
insured children. [24] In addition, uninsured children, a majority
of whom are immigrants or the children of immigrants, delay
needed preventive care such as immunizations, well-child
screenings, and management of chronic medical conditions
like asthma. Similarly, uninsured individuals are more likely
to delay seeking treatment for potentially serious conditions
until treatment is more costly and less effective. [25]

California and some other states use state funds to
provide Medicaid or SCHIP coverage to legal immigrants
who arrived in the United States after the enactment of
PRWORA. However, high-immigrant states like California
have become vulnerable to cutbacks recently. [26] But limiting
access to health care for immigrants by restricting health
insurance coverage is likely to have a negative impact on the
health and welfare of the immigrant population. A 2000 study
found that eliminating public funding for prenatal care for
undocumented immigrants in California could result in lower
birth weights, more premature births, and higher post-natal
health care costs. [27]

Directions For Future Research

More research is urgently needed to facilitate greater
access to health care for immigrants. Effective health
care policies require an understanding of the specific needs
and patterns of health care utilization among immigrants.
Numerous studies have found that newly-arrived immigrants
tend to have healthier lifestyles than native-born individuals,
but these advantages diminish over time. Further research is
needed on how health behaviors, health status, and insurance
coverage change the longer an immigrant resides in the
United States. [28]

Research also is needed to identify culturally and
linguistically sensitive approaches to encourage immigrants
to seek proper preventive health care. Language and cultural
differences are major barriers to health care for immigrants.
According to the 2000 Census, over 18 percent of the U.S.
population speaks a language other than English at home.
Immigrants who do not speak English as a primary language
experience greater problems accessing the health care system.
For example, only a third (36 percent) of non-citizen Spanish-speaking
Latino adults had seen a doctor in the previous
year. [29] One study at an inner city clinic found that one in nine
immigrant parents reported that they had not brought their
children in for health care because they felt that the medical
staff did not understand Latino culture. [30]

Overcoming these linguistic and cultural barriers requires
expanding, and providing timely reimbursement for, interpreter
services, and increasing the number of linguistically
and culturally competent staff. Often, methods to reduce
culture and language barriers must be community-based
rather than hospital or clinic-based, since a substantial proportion
of immigrants do not enter the health care system regularly. Health care providers serving immigrant communities
should work in concert with community groups, as well
as with public health, social service, and school systems. For
example, health care providers and researchers developed
culturally appropriate educational materials and workshops
to promote oral health among pregnant women in New York
City when they discovered, through surveys, that low-income
immigrant women knew very little about oral health. [31] As
another example, bilingual and bicultural outreach staff in
New York worked with immigrant communities to correct
cultural misunderstandings about tuberculosis and lessen the
fear of being stigmatized by the disease. [32]

Conclusion

The widely held assumption that immigrants consume
large amounts of scarce health care resources is invalid.
Moreover, the government does not avoid health care costs
by limiting immigrants' access to health insurance programs.
In fact, using public funds to provide comprehensive health
care for low-income immigrants fosters individual and public
health and is cost-effective. [33] Comprehensive coverage reduces
the unnecessary use of high-cost emergency room care and
inpatient hospital visits. Key to health care policy on behalf
of immigrants and to public health in general is expanding
access to affordable health insurance. The future economic
success of the United States depends on a healthy workforce.
Therefore, policies must be devised that improve, rather than
restrict, immigrants' access to quality health care.

3 Stuart Anderson, The Contribution of Legal Immigration to the Social Security System. Arlington, VA: National Foundation for American Policy, February 2005 (revised March 2005), p. 1.

4 Office of the Inspector General, Social Security Administration, Obstacles to Reducing Social Security Number Misuse in the Agriculture Industry (Report No. A-08-99-41004), January 22, 2001, p. 12.

5 Testimony of Patrick P. O’Carroll, Assistant Inspector General for Investigations, Social Security Administration, before the U.S. House of Representatives, Committee on Ways and Means, Subcommittee on Oversight and Subcommittee on Social Security, regarding "Social Security Number and Individual Taxpayer Identification Number Mismatches and Misuse," March 10, 2004.

6 International Migration Policy Program of the Carnegie Endowment for International Peace & the Urban Institute, "Immigrants and Welfare," Research Perspectives on Migration 1(1), September/October 1996, p. 8.

10 Sarita A. Mohanty, et al., "Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis," American Journal of Public Health 95(8), August 2005, p. 1431-1438. The study used the 1998 Medical Expenditure Panel Survey linked to the 1996–1997 National Health Interview Survey to analyze data on 18,398 native-born persons and 2,843 immigrants.

11 University of California, Los Angeles (UCLA) Center for Health Policy Research and the National Population Council of the Government of Mexico (CONAPO), Mexico-United States Migration: Health Issues, October 2005.

15 Olveen Carrasquillo, et al., "Health insurance coverage of immigrants living in the United States: differences by citizenship status and country of origin," American Journal of Public Health 90(6), June 2000, p. 917-23.

24 Melinda L. Schriver, No Health Insurance? It’s Enough to Make You Sick: Latino Community at Great Risk. Philadelphia, PA: American College of Physicians–American Society of Internal Medicine, March 2000, p. 11.